The Worst Time for a Hospital Visit

This week in “Doctor and Patient,” I write about how four factors — hospital occupancy, weekend admissions, nurse staffing and the seasonal flu — can not only increase the risk of dying in a hospital but can also interact in variable ways.

The result of this interplay, according to a study published this month in the journal Medical Care, is that each hospital has a unique threshold — its own “fingerprint,” according to one of the study authors — beyond which patient safety becomes compromised. One hospital may find that a four-to-one patient-to-nurse ratio and 70 percent occupancy borders on hazardous, whereas another hospital that serves a healthier population will work efficiently at the same staffing ratio until at least 90 percent of the beds are occupied.

In reading through the study, I remembered how people who work in hospitals often ask, “When is the worst time to be a patient in the hospital?” But a non-doctor friend reminded me recently that it’s a question patients spend a lot of time thinking about, too. “I thought about it all the time when I was pregnant,” she said. “I didn’t want to deliver on the weekend or a holiday or when my doctor wasn’t around.”

Although the authors of the study emphasized the variability among institutions and couldn’t provide any absolute rules, they did offer a few suggestions to anyone contemplating elective surgery or admission.

“I think for very specific areas like transplantation, there is a value in patient volume,” said Dr. Darrell A. Campbell Jr., an author of the study and chief of clinical affairs at the University of Michigan Health System. “But if the referrals are such that the overall hospital occupancy gets too high, you might want to re-consider your choice.”

Dr. Matthew Davis, an associate professor of pediatrics, internal medicine and public policy at the University of Michigan and senior author of the study, suggested that patients get their seasonal flu vaccinations and speak to their doctors about the timing of their procedure or admission, particularly in relation to the hospital’s overall work flow. “I think that would be a particularly good conversation for people planning to have elective surgery,” Dr. Davis said. “Not all of this improvement in safety has to happen within the fours walls of a hospital.”

These kinds of discussions can have other implications for patients. “Death is the most grim outcome measure,” said Dr. Peter L. Schilling, lead author of the study and a resident in orthopedic surgery at the University of Michigan. “But it’s not hard to imagine how all of these things could also affect a patient’s experience.”

To learn more about factors influencing in-hospital mortality risks and what can be done about them, read my column, “When Is the Worst Time to Go to the Hospital?” and then please join the discussion below. Have you ever thought about the worst time to be a patient in a hospital?

Do most hospitals have enough nursing staff working at any given time to have a 4:1 nurse-to-patient ratio or is that ratio just meant as an example? (I’ve never worked in healthcare, so I have no idea. That just sounds like a lot of people.)

nurses and residents shift from 7-7:30 (AM and PM). This is the worst time to give birth in the hospital — not that it’s under your control but be aware that your needs may be neglected during that time slot so speak up loudly if you really need attention! And I agree – July sucks.

There’s actually NEVER a good time. Hospitals are full of sick people and germs. If you can get your ailments diagnosed as an outpatient, or have ambulatory surgery instead of being admitted, that’s the way to go.

Unfortunately, with hospitals being paid “per case” by medicare, they have great incentives to get you out the door as soon as they can, the shorter the stay the more profit they make! Even if you can’t walk or eat well yet, out you go, and if you come back with a fever or severe pain, they get to re-admit you and bill medicare again. When the healthcare reform bill is passed, medicare fees will be cut further, less doctors will accept medicare and not only will you be rushed out the door as soon as they can get you into a taxi.

With “reform”, your hospital stay will be spent more with interns, nurses and technicians than with doctors, who are paid so little to visit you they rely on the hospitalists or residents to work on you. The final word- go only when you really, really have to, and ask a lot of questions to anyone who wants to touch you while you’re there!

July is a bad time to have surgery, but August is much worse. This is when new anesthesia residents are left alone in the operating room without a senior anesthesiologist. In July, they are supervised full-time. I would advise anyone with a choice to avoid August.

My son, five at the time, broke his ankle last spring in the height of the H1N1 outbreak. We sat in the lobby of Columbia-Presbyterian, which had been set up for triage because the pediatric ER was overflowing, for several hours waiting for an x-ray. Fortunately, we didn’t come down with anything in the next few days! At the same time, I was incredibly impressed at the calm and professionalism of every staff member we came into contact with during the visit, despite the fact that the place was incredibly busy.

I would expect hospital administrators to work at keeping beds occupied with patients capable of providing income to the hospital rather than concern themselves with being able to cope with an unexpected influx. In our community, we avoid the ER on weekends because it is usually filled with drunken college students, college students injured by drunks, and the like. (It’s even worse when there’s a football game that weekend.) Pity the person with a real medical emergency when all the spaces are filled with vomiting dolts with alcohol toxicity.

I actually think July isn’t the worst time — it is the time you will probably spend the longest time waiting as a patient, as people are inefficient…but because it’s the start of the new crop of interns and residents, there is a lot more caution, supervision and doublechecking of orders.

Recently my spouse was in the hospital for a fractured
Sacrum bone ,and in great pain ,the Hospitalist on call
that Wednesday,came in sadly and said her MRI was
consistent with Bone Leukemia .We started crying.
He never checked
my wife’s blood work which included T cell and white
cell screening to know that they were normal,no cancer.
So actually the best time to go to a hospital is when you
have a smart Doctor on call.

My husband had major spinal surgery on the Thursday before Labor Day weekend, 2009. I would never schedule a surgery at that time again, if I had a choice. From Friday afternoon thought Monday night, the cafeteria was closed. Oh yes, there were candy and coffee machines, so I lived on potato chips and juice.
Never schedule before a holiday weekend.
BTW, the MD did the surgery on Thursday and then promptly left for a weekend vacation even though his office had told me he would be around. Coverage was provided, but it would have been nice to see the surgeon before we left for home on Monday.//www.caringisnotenough.net

During my pregnancy, I was often told that breast feeding in the first few hours and days of the baby’s life is important in establishing successful nursing, along with an almost militant chorus of “breast is best” (and I don’t disagree). I had an emergency c-section on a Friday, had trouble with breast feeding right away, and only then found out that lactation consultants don’t work weekends. So, best time to give birth? Monday to Friday, 9-5. Keep that in mind, ladies.

My local hospital has a 3:1 patient to nurse ratio. However, I believe this is because it is a big world-renowned teaching hospital that always is at (or very near) 100% capacity. Even with it being one of the top five hospitals in the U.S., the quality of the nurses dropped tremendously when I was there over Thanksgiving. The need for travel nurses to step in during the holidays made me feel particularly vulnerable late at night. I didn’t have a choice but I would urge anyone to avoid hospital stays near major holidays. Though I doubt most people being admitted have any choice in the matter and the risks at the hospital are still less than trying to “hold out” until a holiday is over — better to be in the hospital and getting treatment than to make yourself worse by avoiding the place.